Endoscopy, in full.

Perform individual gastric risk assessment and staging of precancerous conditions at first-time gastroscopy, irrespective of the patient's country of origin. Use high quality endoscopy with virtual chromoendoscopy (VCE), after proper training, for screening, diagnosis and staging of atrophy and intestinal metaplasia and after endoscopic therapy; VCE guides the biopsy site, with random biopsies taken only when there are no endoscopically suspected changes. Take biopsies from at least two topographic sites, 2 from the antrum/incisura and 2 from the corpus, VCE-guided, in two separate, clearly labeled vials; an additional incisura biopsy is optional, not required. Stage with validated endoscopic classifications of atrophy (e.g. Kimura-Takemoto) or intestinal metaplasia (e.g. EGGIM) to stratify gastric cancer risk (suggestion, weaker than the biopsy recommendation). Follow up patients with extensive endoscopic changes (Kimura C3+ or EGGIM 5+) OR an advanced histological stage that reaches OLGA/OLGIM III/IV, severe atrophy or intestinal metaplasia and/or significant changes in both antrum and corpus rising to stage III/IV, not any intestinal metaplasia or any antrum-plus-corpus involvement on its own, with high quality endoscopy every 3 years, irrespective of country of origin (strong recommendation, moderate quality). Propose NO surveillance for patients with mild to moderate atrophy or intestinal metaplasia restricted to the antrum, in the absence of endoscopic signs of extensive lesions or other risk factors (family history of gastric cancer, incomplete intestinal metaplasia, persistent H. pylori infection), the guideline states this group constitutes most individuals found in clinical practice. Eradicate H. pylori in all patients with precancerous conditions and after endoscopic or surgical therapy. Discontinue or do not start gastric cancer screening or surveillance in asymptomatic individuals over 80, and weigh comorbidities when planning treatment of superficial lesions. Advise smoking cessation; low-dose daily aspirin may be considered for gastric cancer prevention only in selected individuals already at high cardiovascular risk. For visible neoplasia, use ESD for differentiated lesions clinically staged as dysplastic (low or high grade) or intramucosal carcinoma (any size if not ulcerated, or ≤30 mm if ulcerated), with EMR an alternative for Paris 0-IIa lesions ≤10 mm with low likelihood of malignancy. At the population level, endoscopic screening is suggested every 2-3 years in high-risk regions (age-standardized rate >20 per 100,000 person-years), every 5 years in intermediate-risk regions (ASR 10-20) only if cost-effectiveness has been proven, and not at all in low-risk regions (ASR <10).

Diagnosis is unchanged and still follows the separate ESGE diagnostic guideline (Endoscopy 2025;57:166-185). Start with MRI/MRCP plus laboratory tests, read CA19-9 only after decompression, and check IgG4 when IgG4-related sclerosing cholangitis is suspected. For distal extrahepatic strictures with no pancreatic mass, do combined same-session EUS-guided tissue acquisition plus ERCP brushing and biopsy. For perihilar strictures, sample by ERCP first and move to cholangioscopy-guided biopsy if the result is indeterminate. Do not place an uncovered SEMS (USEMS) until malignancy is confirmed. Management now follows the 2026 ESGE biliary stricture management guideline, which replaces the 2018 stenting guideline and brings it into line with the 2022 therapeutic EUS guideline. Benign: post-cholecystectomy strictures get temporary multiple plastic stents (MPSs), exchanged every 3-4 months with as many stents as possible, for about 12 months. A fully covered SEMS (FCSEMS) is an option only if the stricture is more than 2 cm below the hepatic confluence or the patient will not comply with repeated ERCPs. Anastomotic strictures after liver transplant get MPSs, or a temporary FCSEMS if more than 2 cm below the confluence. Nonanastomotic post-transplant strictures that can be treated endoscopically get MPSs plus balloon dilation if needed. Chronic pancreatitis strictures get a temporary 8-10 mm FCSEMS for 6-12 months. High-grade PSC strictures get balloon dilation alone, with no stent, because stenting adds no benefit and may add adverse events. Endotherapy is indicated for a benign stricture with liver tests raised for more than 1 month and/or cholangitis. Malignant distal: drain before surgery only selectively (cholangitis, severe jaundice or pruritus, delayed surgery). When drainage is needed before surgery or neoadjuvant therapy, or for palliation, place a 10-mm SEMS endoscopically. Endoscopic drainage is preferred over surgery or PTBD for inoperable obstruction. Malignant hilar: manage in high-volume centres with a hepatobiliary multidisciplinary team (MDT). ERCP is preferred over PTBD for preoperative drainage. Palliate Bismuth I-II with ERCP. For Bismuth III-IV, ERCP or ERCP combined with EUS-guided drainage (EUS-BD) is preferred over primary PTBD, with PTBD as a complement if needed. For proven Bismuth II-IV, aim to drain more than 50%, ideally 70% or more, of the viable nonatrophic liver volume using several routes as needed. Use plastic stents when the drainage strategy is undefined or the centre is not expert. USEMS are for expert centres when the diagnosis is proven, the tumour is unresectable, and complete drainage is predicted. After failed or unfeasible ERCP, EUS-BD is recommended over PTBD. Use hepaticogastrostomy (EUS-HGS) if there is a duodenal stricture, and EUS-HGS or choledochoduodenostomy (EUS-CDS) if there is not. PTBD is used if EUS-BD fails. In surgically altered anatomy, benign disease gets enteroscopy-assisted ERCP first; malignant disease gets enteroscopy-assisted ERCP or EUS-BD. Give antibiotics before ERCP in selected cases: predicted incomplete drainage, hilar strictures, immunocompromised patients, PSC, cholangioscopy. This follows the ESGE ERCP-adverse-events guideline. Etiology-specific care (Strasberg injuries, IgG4-SC, Mirizzi, choledochal cysts) is unchanged.

Address the specific underlying cause of persistent or new post-cholecystectomy symptoms after narrowing the heterogeneous differential (retained/CBD stone, sphincter of Oddi dysfunction, bile leak/duct injury, bile acid diarrhea, functional dyspepsia/IBS, GERD). First exclude time-sensitive early postoperative complications, bile leak/duct injury, obstructing retained/CBD stone, biliary obstruction or cholangitis, and treat red-flag features (jaundice, fever, sepsis, or early-onset/worsening pain) as warranting prompt evaluation rather than reassurance; only then reassure that most symptoms settle within 6-12 months, avoid empiric reoperation, and obtain multidisciplinary GI + HPB surgery input for refractory or atypical cases.

For right upper quadrant pain, characterize the pattern (acute vs chronic, post-meal vs unrelated, with vs without fever/jaundice) and triage acute red-flag presentations (Murphy sign, Charcot's triad, painless jaundice with weight loss, pregnancy with LFT/coagulation derangement) to the ED. Obtain labs (CBC, CMP with LFTs, lipase, urinalysis, pregnancy test in reproductive-age women) and RUQ ultrasound as first imaging, then direct further workup by ultrasound findings, cholecystectomy for acute cholecystitis, MRCP for suspected choledocholithiasis based on risk stratification (e.g., high-risk criteria including CBD dilation >6 mm, bilirubin >4 mg/dL, or gallstone pancreatitis), CCK-HIDA/GBEF for acalculous functional gallbladder disorder, and cross-sectional imaging for liver masses or other pathology.

U.S. Multi-Society Task Force (2017 guideline, revised by the 2022 focused update on age to start and stop): offer average-risk colorectal cancer screening to everyone aged 45-75. Screening at 45-49 is a weaker recommendation than at 50-75. Colonoscopy every 10 years and annual FIT are the Tier 1 cornerstones. Tier 2 alternatives are multi-target stool DNA every 3 years, CT colonography every 5 years, and flexible sigmoidoscopy every 5-10 years. Capsule colonoscopy every 5 years is Tier 3. Any abnormal non-colonoscopy test requires a diagnostic colonoscopy, and a stool test should not be offered to a patient who would decline follow-up colonoscopy. Patients who are up to date with negative prior screening, particularly a high-quality colonoscopy, may consider stopping at 75 or when life expectancy is under 10 years. Decisions at 76-85 are individualized by health and prior screening, and screening after 85 is not recommended. The American Cancer Society's May 2026 guideline agrees on the 45-75 range, no screening after 85, and colonoscopy as the preferred option. It adds the next-generation mt-sDNA test and the multitarget stool RNA test (ColoSense), both every 3 years, and it adds an FDA-approved blood-based cfDNA test (Shield) only for people who decline or do not complete visual or stool screening. ACS says a positive stool or blood test should be followed by colonoscopy, preferably within 6 months. The 2026 ASGE paper on follow-up after an abnormal stool test is an implementation review (navigation, tracking, direct-access colonoscopy), not a new screening guideline.

U.S. Multi-Society Task Force (2017 guideline, revised by the 2022 focused update on age to start and stop): offer average-risk colorectal cancer screening to everyone aged 45-75. Screening at 45-49 is a weaker recommendation than at 50-75. Colonoscopy every 10 years and annual FIT are the Tier 1 cornerstones. Tier 2 alternatives are multi-target stool DNA every 3 years, CT colonography every 5 years, and flexible sigmoidoscopy every 5-10 years. Capsule colonoscopy every 5 years is Tier 3. Any abnormal non-colonoscopy test requires a diagnostic colonoscopy, and a stool test should not be offered to a patient who would decline follow-up colonoscopy. Patients who are up to date with negative prior screening, particularly a high-quality colonoscopy, may consider stopping at 75 or when life expectancy is under 10 years. Decisions at 76-85 are individualized by health and prior screening, and screening after 85 is not recommended. The American Cancer Society's May 2026 guideline agrees on the 45-75 range, no screening after 85, and colonoscopy as the preferred option. It adds the next-generation mt-sDNA test and the multitarget stool RNA test (ColoSense), both every 3 years, and it adds an FDA-approved blood-based cfDNA test (Shield) only for people who decline or do not complete visual or stool screening. ACS says a positive stool or blood test should be followed by colonoscopy, preferably within 6 months. The 2026 ASGE paper on follow-up after an abnormal stool test is an implementation review (navigation, tracking, direct-access colonoscopy), not a new screening guideline.

Outpatient positioning is unchanged from the ACG 2025 UC guideline and the AGA living guideline for moderate-to-severe UC. Confirm UC with endoscopy showing continuous colonic inflammation from the rectum plus histology, after excluding infection with two-step C. difficile testing. Treat mild-moderate disease with 5-ASA chosen by route and extent: suppository for proctitis, enema for left-sided disease, oral plus rectal for extensive disease. If 5-ASA fails, treat as moderate-to-severe rather than stepping up gradually. Position advanced therapy by efficacy tier, not by an anti-TNF-first rule. Advanced-therapy-naive, higher efficacy: infliximab, vedolizumab, ozanimod, etrasimod, upadacitinib, risankizumab, guselkumab. Intermediate: golimumab, ustekinumab, tofacitinib, filgotinib, mirikizumab. Lower: adalimumab. Previously TNF-exposed, higher efficacy: tofacitinib, upadacitinib, ustekinumab. Lower: adalimumab, vedolizumab, ozanimod, etrasimod. After anti-TNF primary non-response, switch mechanism rather than cycling within the class. Treat to target (STRIDE-II): endoscopic improvement, Mayo endoscopic subscore 0-1. Begin CRC surveillance 8-10 years after diagnosis for extensive or left-sided disease; isolated proctitis follows average-risk screening. Inpatient care now follows the 2026 AGA Clinical Practice Update (13 best-practice statements). Admit for severe symptoms refractory to outpatient therapy, suspected complications (obstruction, abscess, toxic megacolon) or significant malnutrition, and identify acute severe UC by Truelove-Witts. Give every patient admitted with diarrhea two-step C. difficile testing. Test for CMV, with early endoscopy, if symptoms worsen, the patient is systemically toxic or disease is steroid-refractory. Give routine VTE prophylaxis with LMWH or fondaparinux unless contraindicated, and individualize post-discharge extension. Give IV methylprednisolone 60 mg/day or equivalent; the AGA living guideline says 40-60 mg/day, and higher doses add no benefit. Do not give adjunctive antibiotics without infection. Involve surgery early. Assess response by day 3 (72 h) using stool frequency and CRP (Oxford criteria); do not continue IV steroids beyond about 7 days without response. Rescue steroid non-responders with infliximab (accelerated or intensified dosing in selected patients with high inflammatory burden or protein-losing colopathy), cyclosporine, or a JAK inhibitor at standard or intensified dosing, or with colectomy. Before discharge, the response should be stable and a transition plan should be in place.

Localized GIST: small (<2 cm) oesophagogastric or duodenal submucosal nodules should be assessed by endoscopic ultrasound and kept under annual surveillance, with excision reserved for lesions that grow or become symptomatic; if a biopsy diagnosis of GIST is obtained, resection is advised unless major morbidity is expected. For all other localized disease, standard treatment is complete surgical excision with microscopically negative (R0) margins, wide margins are not required and routine lymph node dissection is unnecessary because nodal involvement is rare, using function-preserving technique and taking care not to rupture the tumour (rupture worsens prognosis and is treated as metastatic risk). After an R1 (microscopically positive) resection, re-excision may be considered if the original site can be identified and major functional consequences are not expected. Mutational analysis of KIT and PDGFRA is standard practice in all GISTs (it may be omitted only for non-rectal GISTs <2 cm) and guides both prognosis and therapy. Adjuvant imatinib 400 mg/day for 3 years is recommended for completely resected tumours at significant (high) risk of relapse, where risk is estimated from mitotic index, tumour size and tumour site (plus rupture); adjuvant treatment is only appropriate when the mutation is imatinib-sensitive and is not indicated for imatinib-insensitive genotypes such as PDGFRA D842V (and is unlikely to benefit SDH-deficient or NF1-associated GIST). Metastatic or unresectable GIST: first-line imatinib 400 mg/day, except for tumours with a KIT exon 9 mutation where the starting dose is 800 mg/day; treatment is continued indefinitely and should not be interrupted, since interruption is generally followed by progression (surgery of residual/responding metastatic disease may be considered on a case-by-case basis). On progression or intolerance, sequential therapy is second-line sunitinib 50 mg/day (4 weeks on / 2 weeks off, or 37.5 mg/day continuously), third-line regorafenib 160 mg/day (3 weeks on / 1 week off), and fourth-line ripretinib 150 mg/day. PDGFRA D842V-mutant GIST is resistant to imatinib and is treated first-line with avapritinib 300 mg/day (these patients do not receive imatinib).

DIAGNOSIS (patient must be on a gluten-containing diet). Serologic testing consists of TTG-IgA plus, if IgA deficiency has not previously been excluded, concurrent total IgA; if IgA deficiency is present, measure an IgG-based serology (DGP-IgG and/or TTG-IgG). This algorithm, previously restricted to those >=2 years, now applies to adults and children at ANY age. An elevated TTG-IgA should proceed to EGD with duodenal biopsy. A negative TTG-IgA in a non-IgA-deficient patient adequately rules out CD only when pretest probability is low or moderate; in symptomatic patients whose pretest suspicion is high (>5%), EGD with duodenal biopsy should be performed irrespective of serologic result. ACG recommends EGD with multiple duodenal biopsies to confirm the diagnosis in both children and adults with suspicion of CD (STRONG recommendation, moderate quality; 1 dissent); sampling should be 1 or 2 biopsies from the bulb (9-o'clock or 12-o'clock position) and at least 4 from the distal duodenum. Lymphocytic duodenosis (>=25 IELs/100 epithelial cells) without villous atrophy is NOT specific for CD. NONBIOPSY PATHWAY (CONDITIONAL recommendation, moderate quality): a combination of high-level TTG-IgA (>10x ULN) with a positive EMA in a SECOND blood sample is suggested as reliable for diagnosis in CHILDREN, and only if the family agrees with the no-biopsy strategy; in SYMPTOMATIC ADULTS unwilling or unable to undergo upper GI endoscopy the same criteria may be considered AFTER THE FACT, as a diagnosis of 'likely CD', ACG does not endorse a prospective no-biopsy pathway in adults, noting a >=10-fold TTG-IgA elevation carries a PPV of only ~95% in adults, which may be unacceptably low given lifelong treatment implications. HLA-DQ2/DQ8 is not required for diagnosis but is useful for serology-histology discrepancy or in patients already on a GFD; if negative, CD is ruled out. TREATMENT AND MONITORING. Strict lifelong GFD. A visit with a dietitian after diagnosis is MANDATORY, with subsequent visits as needed to reinforce education and adherence encouraged; interview with a dietitian experienced in the GFD is the standard of care for assessing adherence. ACG RECOMMENDS consumption of gluten-free oats (STRONG recommendation, moderate quality), with the qualifier that gluten contamination of oats, variable toxicity across oat varieties, and a small risk of immune reaction to avenin require monitoring for oat tolerance (monitoring intervals are not known). ACG suggests AGAINST routine use of gluten detection devices in food or biospecimens (conditional, low quality; 1 dissent), and finds INSUFFICIENT EVIDENCE to recommend for or against probiotics (evidence gap). ACG suggests setting a goal of intestinal healing as an end point of GFD therapy, advocating individualized discussion of goals beyond clinical and serological remission (CONDITIONAL recommendation, low quality). Follow-up may require multiple visits in the first year (e.g. 3, 6, and 12 months) and regular visits (e.g. twice a year or yearly) thereafter, tracking symptoms and TTG or DGP serology; other tests may include CBC, ALT, AST, vitamins A/D/E/B12, copper, zinc, folic acid, ferritin, and iron, with follow-up bloodwork individualized to verify correction of values abnormal at baseline. Preventive care includes vaccines and DXA. Symptoms improve within days of strict adherence (diarrhea improved in 80% within 60 days), but mucosal healing lags: median time from GFD onset to mucosal healing in adults is 3 years, so it is reasonable to consider a follow-up biopsy in adults after 2 years of starting a GFD, in the ABSENCE of symptoms, after shared decision-making; children heal faster (95% within 2 years), altering the risk-benefit calculus. Repeat biopsy is the only reliable method to document mucosal healing, seroconversion correlates poorly. Upper endoscopy with biopsies is also indicated for lack of clinical response or relapse of symptoms despite a GFD. VACCINATION: ACG suggests vaccination to prevent pneumococcal disease in patients with CD (CONDITIONAL recommendation, low quality), because increased pneumococcal risk is attributed to hyposplenism (frequently subclinical) present in roughly one-third of patients. The regimen follows CDC recommendations by age, immunization record, and comorbidity: for an adult with CD and functional asplenia not previously vaccinated or with unknown history, 1 dose of PCV15 (followed by PPSV23 at least 1 year later) or 1 dose of PCV20 (no PPSV23 indicated); for an adult with CD and no other condition carrying a specific CDC recommendation, ACG suggests 1 dose of PCV20 alone, or 1 dose of PCV15 first and then consider PPSV23 at least 1 year later. NONRESPONSIVE CD (NRCD): defined as persistent symptoms, signs, or laboratory abnormalities typical of CD despite 6-12 MONTHS of dietary gluten avoidance. Evaluation should review and confirm the initial diagnosis of CD, assess for inadvertent gluten exposure (via expert dietitian assessment and serology, positive serologies despite 12 months of GFD suggest ongoing gluten ingestion), assess for a coexisting functional disorder, and selectively test based on clinical suspicion for food intolerances (e.g. lactose, fructose), pancreatic insufficiency, microscopic colitis, and small intestinal bacterial overgrowth, among others. REFRACTORY CD (RCD) is a separate, rarer entity (<1% of patients outside referral centers): ongoing malabsorptive symptoms and signs with villous atrophy despite strict adherence to a GFD for MORE THAN 12 months and absence of other disorders including overt lymphoma; initial assessment centers on distinguishing RCD type 1 from type 2 by CD3/CD8 immunostains, T-cell receptor clonality by PCR, and/or flow cytometry of duodenal biopsies.

For ALL patients undergoing ERCP (average-risk and high-risk alike), give periprocedural rectal NSAID prophylaxis (100 mg indomethacin or diclofenac) unless contraindicated (e.g., recent PUD, renal insufficiency), this is now a strong recommendation for unselected patients, not just high-risk ones. For high-risk patients undergoing repeated or deep pancreatic-duct access or ampullectomy, add a prophylactic small-caliber pancreatic duct stent (3-5Fr, preferably 5Fr, 3-7cm, removed within 5-10 days), strong recommendation; for other high-risk scenarios (difficult cannulation, prior PEP, precut sphincterotomy without fistulotomy), PD stenting is a conditional recommendation when PD access is easily achieved. Aggressive periprocedural/postprocedural IV hydration with lactated Ringer's (20 mL/kg bolus, then 3 mL/kg/h for 8h) is a conditional suggestion for unselected patients (most practical for inpatients), and wire-guided cannulation is conditionally favored over contrast-guided to reduce PEP risk. The SVI trial (Elmunzer, Lancet 2024) found rectal indomethacin alone did NOT meet non-inferiority versus indomethacin+stent in high-risk patients (PEP 14.9% vs 11.3%), supporting continued use of the combination bundle in high-risk cases rather than dropping the stent. Post-procedure, monitor for the major complications (pancreatitis, sphincterotomy bleeding, perforation, cholangitis) and manage by type, PEP by Cotton criteria with fluids/analgesia, bleeding with repeat endoscopic hemostasis, perforation by Stapfer classification with surgical consult for Type I, and cholangitis with empiric antibiotics (Tokyo Guidelines TG18) plus biliary drainage; these complication-management elements are unchanged from ESGE 2020.

Two current US guidelines govern Crohn's disease and should be read together. ACG 2025 (Lichtenstein et al.) remains the reference for diagnosis, mild-to-moderate disease, perianal, postoperative and abscess management. DIAGNOSIS: fecal calprotectin (>50-100 μg/g) separates inflammatory from noninflammatory disease of the colon. Workup is ileocolonoscopy with biopsies, including uninvolved mucosa, plus small-bowel imaging. CTE and MRE are comparable; prefer MRE in patients <35 y and when serial exams are likely. Intestinal ultrasound is an ungraded adjunct. Do routine CRC surveillance in Crohn's colitis. MILD-TO-MODERATE: recommend against oral mesalamine; sulfasalazine only for symptomatic mild colonic CD; ileal-release budesonide 9 mg for induction in ileocecal disease but not for maintenance. MODERATE-TO-SEVERE (AGA Living Guideline, Scott et al., Gastroenterology 2025;169(7):1397-1448, 16 recommendations: 1 strong, 9 conditional, 6 knowledge gaps; updated quarterly, adult outpatients only): RECOMMEND infliximab, adalimumab, ustekinumab, risankizumab, mirikizumab, guselkumab or upadacitinib over no treatment; SUGGEST certolizumab pegol or vedolizumab over no treatment. Advanced-therapy-naive: suggest higher-efficacy agents (infliximab, adalimumab, vedolizumab, ustekinumab, risankizumab, mirikizumab, guselkumab) over lower-efficacy ones (certolizumab pegol, upadacitinib). Prior advanced-therapy (especially anti-TNF) exposure: suggest higher- or intermediate-efficacy agents (adalimumab, risankizumab, guselkumab, upadacitinib; ustekinumab, mirikizumab) over lower-efficacy ones (vedolizumab, certolizumab pegol). Suggest against thiopurine monotherapy for induction; suggest it for maintenance of remission. Suggest SC/IM methotrexate monotherapy; suggest against oral methotrexate. In thiopurine-naive patients starting infliximab, suggest infliximab + thiopurine over infliximab alone. No recommendation on IFX + MTX, adalimumab + immunomodulator, or non-TNF biologic + immunomodulator. After ≥6 months of steroid-free remission on anti-TNF + immunomodulator, suggest withdrawing the immunomodulator and suggest against withdrawing the anti-TNF. SUGGEST upfront advanced therapy over step-up therapy (corticosteroids and/or immunomodulator first). No recommendation on treating to endoscopic vs symptomatic remission. The ACG 2025 moderate-to-severe recommendations (anti-TNF, IFX + thiopurine combination and IL-12/23/IL-23 agents, each strong/moderate; upadacitinib after anti-TNF exposure; steroids for short-term induction only; TPMT/NUDT15 testing before thiopurines) still stand alongside AGA. ACG perianal (infliximab first; drain abscesses and place setons before escalating), postoperative (endoscopy at 6-12 months; anti-TNF strong, vedolizumab conditional in high-risk patients) and intra-abdominal abscess (>2 cm: antibiotics plus drainage, hold immunosuppression) positions are unchanged. THERAPEUTIC ENDOSCOPY (AGA Clinical Practice Update, CGH 2026; details below come from AGA news coverage, not the full text, and are ungraded advice): get cross-sectional imaging before the procedure. Endoscopic balloon dilation is first-line for short strictures (about ≤4-5 cm) with few risk factors (fistula, prestenotic dilation >5 cm, high CRP, prior anti-TNF). Longer or multiple strictures, or ≥3 risk factors, favor surgery.